Emergency Medical Services, part 1

Tuesday

Oct 18, 2011 at 12:01 AMJul 1, 2012 at 10:52 AM

When we last spoke I had the opportunity to outline for you what you might expect during an encounter in the emergency room (ER). I wanted to dedicate this column to a description of what is involved in getting to the ER.

James Ungar

Hello again.
When we last spoke I had the opportunity to outline for you what you might expect during an encounter in the emergency room (ER). I wanted to dedicate this column to a description of what is involved in getting to the ER.
As you probably know, there are essentially two ways to come to an emergency department: Privately by whatever transportation is available (feet to limousine) and via Emergency Medical Services (EMS). The latter constitutes the extension of emergency medical care into the community. It is a vast subject and one that certainly warrants a detailed description of its history and scope. Because of this I have decided to break this topic into several parts as I can’t do it justice in the space allocated for this column.
The current EMS system in the United States started in 1966 with the National Highway Safety Act, which authorized the Department of Transportation (DOT) to fund ambulances, communications and training programs for prehospital medical services. In 1973, Public Law 93-154 defined a goal of improving emergency medical care and EMS on a national scale. Although much has changed in EMS in the 38 years since it was expanded nationally, an understanding of the 15 elements that made up that 1973 law is useful in understanding what EMS is all about: personnel, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, transfer of care, standardization of patient records, public information and education, independent review and evaluation, disaster linkage and mutual aid agreements.
• Personnel: In most urban areas, paid ambulance personnel provide prehospital care. In rural or wilderness areas, these services are provided by volunteers
• Training: Training begins at the citizen level in understanding the basics of CPR, other first aid and access to the EMS system. Currently, there are four DOT EMS training levels. These are first responders (FR), emergency medical technician (EMT) basic (EMT-B), EMT intermediate (EMT-I) and EMT paramedic (EMT-P).
The FR training is designed for those individuals likely to first encounter in the field emergencies but not as part of an ambulance crew. Included here are police officers, firefighters and community first aid teams. The training involves instruction in CPR, spinal immobilization, bleeding control and other basic emergency care procedures.
The other three DOT training levels are for those individuals who will function as members of an ambulance crew. Some states (such as California) have additional EMT levels besides the three recognized by the DOT.
Our community utilizes the EMT-B category, responders who have the necessary first aid skills to care for immediately life-threatening prehospital conditions, including CPR, use of an automated external defibrillator (AED), and safe extrication, immobilization and transportation of multiple trauma victims. EMT-Bs are now being trained to assist patients in their own use of nitroglycerine, epinephrine (epi-pens) and inhalers for asthma and emphysema.
An advanced module is available in the EMT-B curriculum for advanced airway techniques, whether it be endotracheal intubation or an advanced airway adjunct such as pharyngeal tracheal lumen airways or a laryngeal mask airway (LMA). The added curriculum is at the discretion of the state EMS agency.
EMT-I training includes additional skills in patient assessment and adds such modalities as IV therapy, basic EKG interpretation, defibrillation and the ability to administer some cardiac medications.
The EMT-P training level expands on the EMT-I by adding even more skills and teaching a more comprehensive curriculum that expands on pathophysiology of disease and pharmacology of medications. Obviously, physicians are deeply involved in the training and quality control measures of the various levels of EMTs, as ideally we would like to expand what is done for the patient in the ER to the field encounter with the EMT.
• Communications: In the United States and Canada, the universal phone number to dial for access to the EMS system is 9-1-1. In many sectors the 9-1-1 system is enhanced (E-9-1-1), which allows automatic number and location information to assist responding personnel. Of course this has been complicated lately with the prevalence of cellphones, but technology is rapidly evolving to allow for accurate location of these mobile calls, as well.
The 9-1-1 call is the gateway to the EMS system, and the people receiving these calls are graduates of the Emergency Medical Dispatch (EMD) course that allows for the right ambulance crew to be dispatched to the appropriate location (priority dispatch). Information obtained by dispatch is relayed to the responding crews by a process known as prearrival instruction. Ambulance personnel are directly or indirectly in communication with their destination hospital.
Much care in the field is by standing order or protocol that has been extensively researched by emergency physicians who are responsible for directing the prehospital activities. It is still possible for the EMTs to call the ER directly and talk to either the physician or, more commonly, a mobile intensive care nurse (MICN) in the ER, should circumstances so dictate.
We’ll touch on the remaining 12 elements of the EMS system in the next part of this article and talk a little more about the unique and very special people who put their lives on the line every day to provide us with this most vital service that we all too often take for granted.